Haemoptysis is the coughing of blood from a source below the glottis. It can range from a small amount of blood-streaked sputum to massive bleeding with life-threatening consequences due to airway obstruction, hypoxaemia, and haemodynamic instability.
In a study of patients in primary care, the incidence of haemoptysis was found to be 1 case in 1000 patients per year. Massive haemoptysis occurs in around 5% to 15% of patients presenting with haemoptysis. The rate of bleeding is the most important factor determining mortality.
Various definitions of massive haemoptysis exist. A common definition is the expectoration of blood from a source below the glottis exceeding 600 mL of blood over a 24-hour period or 150 mL of blood (which may flood the lung dead space) over a 1-hour period. However, quantifying blood loss accurately can be a challenge.
Massive haemoptysis can also be defined by its clinical effect:
Airway compromise: obstruction, aspiration, hypoxaemia, need for intubation
Requirement for blood transfusion.
Massive haemoptysis is a medical emergency and should be addressed immediately. Initial priorities are stabilisation of the patient and protection of the non-bleeding lung.
Haemoptysis has numerous possible causes, including tracheobronchial, pulmonary parenchymal, and pulmonary vascular diseases. In the primary care setting, major causes are acute and chronic bronchitis, tuberculosis, lung cancer, pneumonia, and bronchiectasis.
Pseudohaemoptysis versus haemoptysis
The initial diagnostic assessment should aim to differentiate between haematemesis (i.e., the vomiting of blood), pseudohaemoptysis (i.e., the coughing of blood from a source other than the lower respiratory tract), and haemoptysis. Pseudohaemoptysis can occur when:
Haematemesis is aspirated into the lungs
Bleeding from the upper airway or the mouth stimulates a cough reflex
Material is expectorated that looks like blood but is not (e.g., Serratia marcescens infection).
Characteristically, haemoptysis tends to be indicated by bright red, frothy sputum that is alkaline.
Blood from extrapulmonary sources tends to be darker, may have admixed food particles, and is acidic. The exception is when brisk bleeding in the gastrointestinal tract overcomes the acidic environment of the stomach.
Bleeding from the posterior nasal passage or nasopharynx may mimic haemoptysis without obvious epistaxis. Examining the oral and nasal cavities can provide important clues to the source of the bleeding (e.g., telangiectasia in the mouth or nose, etc.).
- Acute bronchitis
- Chronic bronchitis
- Pulmonary tuberculosis
- Lung abscess
- Primary lung cancer
- Lung metastasis
- Anticoagulants, thrombolytic agents
- Toxic inhalation
- Pulmonary thromboembolism
- Mitral valve stenosis
- Left ventricular failure
- Disseminated intravascular coagulation
- Endobronchial and pulmonary mucormycosis
- Endobronchial carcinoid
- Aspiration of foreign body
- Aspiration of gastric contents
- Tracheo-oesophageal fistula
- Bronchial telangiectasia
- Airway trauma
- Dieulafoy's disease
- Thoracic endometriosis
- Pulmonary artery aneurysm
- Fat embolism
- Tumour thromboembolism
- Arteriovenous malformation
- Pulmonary haemorrhagic syndromes
- Granulomatosis with polyangiitis (formerly Wegener's granulomatosis)
- Systemic vasculitis
- Congenital heart disease
- Tricuspid endocarditis
- Bronchogenic cyst
- Factitious haemoptysis
- ACR appropriateness criteria: hemoptysis
- Diagnosis and treatment of hemoptysis
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